Jeffrey L Winters | Mayo Clinic (original) (raw)

Papers by Jeffrey L Winters

Blood

Background: Thrombotic thrombocytopenic purpura (TTP) is a rare disorder that presents with micro... more Background: Thrombotic thrombocytopenic purpura (TTP) is a rare disorder that presents with microangiopathic hemolytic anemia and thrombocytopenia, fevers, renal insufficiency and neurologic features. We reviewed clinical, laboratory, and outcome data for TTP cases with severely deficient versus non-severely deficient ADAMTS13 activity levels. Methods: Mean and median data were from the Surveillance, Epidemiology and Risk Factors for TTP (SERF-TTP) study group for idiopathic TTP cases, the Canadian Apheresis Group (CAG), and five published series (Zheng 2004, Raife 2004, Vesely 2003 (Oklahoma TTP-HUS Registry), Matsumoto 2004 (Japan Referral Center), Bennett 2007). Results: Compared to TTP cases with near-normal ADAMTS13 activity levels (n= 282), TTP cases with severe ADAMTS13-deficiency (n=185) were more likely to have severe thrombocytopenia, normal renal function and neutralizing ADAMTS13 antibodies. Severe ADAMTS13 deficient TTP cases have better overall survival after therapeut...

Blood

Since its emergence as a novel therapy for cutaneous T-cell lymphoma in 1987, extracorporeal phot... more Since its emergence as a novel therapy for cutaneous T-cell lymphoma in 1987, extracorporeal photopheresis (ECP) has gained popularity in the fields of solid organ and stem cell transplantation (Perotti et al Transfus Apher Sci 2015). Though ECP is thought to be associated with few adverse effects, we have anecdotally noted that some patients treated with ECP develop iron deficiency anemia. Anemia has been reported in ECP literature at an incidence of anywhere from 0% to 24.5%, however, the etiology of the anemia has not been described (Quaglino et al Int J Dermatol 2013, Flowers et al Blood 2008, Jaksch et al J Heart Lung Transpl 2012, Dignan et al Bone Marrow Transpl 2014). We performed a retrospective chart review to further investigate the magnitude of this potential adverse effect. Adult patients receiving ECP for any indication at Mayo Clinic Hospital-Rochester were eligible for inclusion. Patients with pre-existing iron deficiency anemia (IDA) or physiologic and/or pharmacolo...

European Journal of Haematology

Journal of Clinical Apheresis

Journal of clinical apheresis, 2018

Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation, Jan 18, 2018

We carried out the first matched retrospective cohort study aimed at studying the safety and effi... more We carried out the first matched retrospective cohort study aimed at studying the safety and efficacy of extracorporeal photopheresis (ECP) for bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT). Medical records of 1325 consecutive adult patients who underwent HCT between 2005 and 2015 were reviewed. Seventy-four patients (median age, 51 years) with a diagnosis of BOS were included in the study. After propensity-score matching for BOS severity, 26 patients who underwent ≥3 months of ECP were matched to 26 non-ECP-treated patients, who were assigned an index date corresponding to the ECP start date for their matched pairs. The rate of decline in FEV percentage predicted (FEV) decreased after ECP initiation (and after index date in the non-ECP group), with no significant difference between the 2 groups (P = .33). On a multivariable analysis that included baseline transplant and pulmonary function test variables, matched related donor HCT ...

American journal of hematology, Jan 19, 2018

Symptomatic hyperviscosity is a well-established phenomenon in Waldenström macroglobulinemia (WM)... more Symptomatic hyperviscosity is a well-established phenomenon in Waldenström macroglobulinemia (WM). Monoclonal IgM can variably impact intrinsic serum viscosity, leading to widely disparate symptomatic thresholds for development of hyperviscosity-related symptoms. Data regarding the predictors of symptomatic hyperviscosity and outcomes related to this complication remain scarce and a recent study proposed that IgM >6000 mg/dL be considered a new criterion for initiating therapy in otherwise asymptomatic (smoldering) WM to pre-empt hyperviscosity-related injury. Herein, we attempt to identify predictors of the development of symptomatic hyperviscosity and its impact in patients with WM. Of 997 WM patients evaluated from January, 1996 through June, 2017, symptomatic hyperviscosity was observed in 130 (13%) patients. Overall survival (OS) of these 130 patients was similar to that of patients without symptomatic hyperviscosity (median: 11.5 versus 11.6 years; p=0.63). On multivariate-...

Journal of clinical apheresis, Jan 18, 2017

Apheresis procedures have a role in treatment of disparate diseases involving many different orga... more Apheresis procedures have a role in treatment of disparate diseases involving many different organ systems. Often the disease processes where apheresis plays a role in treatment are considered "orphan diseases"-relatively rare disease processes that lack specific pharmaceutical agents or established treatment protocols. Many of these disease processes can affect the eye with devastating results for the eyesight of these patients. The unique ability of apheresis to affect disease by modifying blood plasma and modulating disease-causing agents therein renders apheresis procedures valuable tools in the treatment of certain ophthalmologic diseases. This review comprehensively evaluates the role of apheresis in the treatment of ophthalmologic diseases of the eye and surrounding orbit including age-related macular degeneration, bilateral diffuse uveal melanocytic proliferation, paraneoplastic retinopathy, atopic keratoconjunctivitis, sympathetic ophthalmia, and endocrine-associa...

Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis, Jan 29, 2016

Apheresis Medicine is a medical discipline that involves a variety of procedures (based on the ta... more Apheresis Medicine is a medical discipline that involves a variety of procedures (based on the targeted component to be removed or collected), indications (therapeutic vs. donation), and personnel (operators, management, and medical oversight). Apheresis services are accredited and/or regulated by a number of agencies and organizations. Given the complexity and the heterogeneity of apheresis services, it has been particularly challenging to formulate educational goals and define curriculums that easily cover all aspects of Apheresis Medicine. This review summarizes the current state of the discipline in the United States of America, and some of the challenges, strategies, and resources that Apheresis Medicine educators have used to ensure that Apheresis Medicine educational programs meet the health care needs of the relevant population within regulatory and accrediting entity frameworks.

Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 2016

Babesiosis is a zoonotic disease transmitted by Ixodes ticks seen in the United States and parts ... more Babesiosis is a zoonotic disease transmitted by Ixodes ticks seen in the United States and parts of Europe. Because of the typically mild course of most infections, the disease is uncommonly seen in clinical practice. However, asplenic patients can develop a life-threatening infection. The first line of therapy for Babesia infections is antiparasitic medications; however, red blood cell (RBC) exchange transfusion has been described as an adjunct therapy. We describe a severe case of babesiosis in an asplenic patient and review the evidence, indications, and protocols for RBC exchange transfusion in this setting.

Mayo Clinic proceedings, Sep 3, 2016

Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common... more Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common histopathologic finding of endothelial damage resulting in microvascular thromboses and potentially serious complications. The typical clinical presentation is microangiopathic hemolytic anemia accompanied by thrombocytopenia with varying degrees of organ ischemia. The differential diagnoses are generally broad, while the workup is frequently complex and can be confusing. This statement represents the joint recommendations from a multidisciplinary team of Mayo Clinic physicians specializing in the management of TMA. It comprises a series of evidence- and consensus-based clinical pathways developed to allow a uniform approach to the spectrum of care including when to suspect TMA, what differential diagnoses to consider, which diagnostic tests to order, and how to provide initial empiric therapy, as well as some guidance on subsequent management.

The Journal of the Kentucky Medical Association, 2003

The patient benefit from reduction of an excessively elevated low density lipoprotein (LDL) chole... more The patient benefit from reduction of an excessively elevated low density lipoprotein (LDL) cholesterol is now well established, especially when there is proven coronary atherosclerosis. Dietary adherence can lower LDL cholesterol by a maximum of 10% to 15%. The addition of a cholesterol-lowering medication frequently can achieve a major LDL cholesterol reduction. However, a small group of patients with a very high LDL cholesterol respond poorly to diet and pharmaceutical treatments. These same patients have the highest incidence for very premature coronary atherosclerosis and associated cardiac events. A few medical centers, including the University of Kentucky, have established a new program to benefit these difficult high-risk patients. The technique is known as LDL apheresis, an effective process for removal of LDL cholesterol. The procedure is highly effective but very costly and third-party approval barriers are preventing access to this essential treatment for some very high-risk coronary atherosclerosis patients.

Urology, Jan 8, 2016

To evaluate the safety and efficacy of intraoperative tranexamic acid (TA), an antifibrinolytic, ... more To evaluate the safety and efficacy of intraoperative tranexamic acid (TA), an antifibrinolytic, in reducing perioperative blood transfusion (PBT) for patients undergoing open radical cystectomy (RC) for bladder cancer. We instituted a change in our institutional clinical practice starting in April 2013 whereby all patients undergoing open RC were administered intraoperative intravenous TA. Patients with a history of venous thromboembolism (VTE) or coronary stent insertion within the year prior to RC did not receive TA. Receipt of a PBT, defined as transfusion of red blood cells during RC or within the postoperative hospitalization, and VTE within 30 days of RC, were recorded and compared to a matched cohort of patients treated with RC at our center prior to the initiation of TA utilization. A total of 103 patients received TA during open RC between April 2013 and July 2015. These patients were matched 1:2 to historic controls. We found that TA infusion was associated with a signifi...

Journal of clinical apheresis, Jan 6, 2016

Anti-muscle specific kinase antibody positive (MuSK Ab) myasthenia gravis (MG) patients are known... more Anti-muscle specific kinase antibody positive (MuSK Ab) myasthenia gravis (MG) patients are known to have different clinical course compared to anti-acetylcholine receptor Ab positive MG patients. Therapeutic plasma exchange (TPE) has been reported to be effective; however, little is known of the response and of TPE procedural information. An ASFA Apheresis Registry was developed to analyze those data. The study collected detailed de-identified patient data, TPE procedures, and treatment outcome/complications. Collected data was described in aggregate. A total of 15 MuSK Ab MG patients with exacerbation of MG symptoms, 13 females/2 males, median age 44, were investigated. Thirty TPE courses (median 5 procedures/course, total 145 procedures) were evaluated. All TPE procedures were performed with citrate anticoagulation, 1 - 1.25 plasma volume exchange in 100% fluid balance, and 90% of courses used only albumin as replacement. Calcium was added to albumin or given orally as needed. TP...

Biology of Blood and Marrow Transplantation, 2016

Retrospective studies have reported that the collected and infused autograft absolute lymphocyte ... more Retrospective studies have reported that the collected and infused autograft absolute lymphocyte count (A-ALC) affects clinical outcomes after autologous peripheral hematopoietic stem cell transplantation (APHSCT). We hypothesized that manipulation of the apheresis machine to target a higher A-ALC dose would translate into prolonged progression-free survival (PFS) in patients with non-Hodgkin lymphoma (NHL) undergoing APHSCT. Between December 2007 and October 2010, we performed a double-blind, phase III, randomized study randomly assigning 122 patients with NHL to undergo collection with the Fenwal Amicus Apheresis system with our standard settings (mononuclear cells offset of 1.5 and RBC offset of 5.0) or at modified settings (mononuclear cells offset of 1.5 and RBC of 6.0). The primary endpoint was PFS. Neither PFS (hazard ratio [HR] of modified to standard, 1.13; 95% confidence interval [CI], .62 to 2.08; P ¼ .70) nor overall survival (OS) (HR modified to standard, .85; 95% CI, .39 to 1.86; P ¼ .68) were found to differ by collection method. Collection of A-ALC between both methods was similar. Both PFS (P ¼ .0025; HR, 2.77; 95% CI, 1.39 to 5.52) and OS (P ¼ .004; HR, 3.38; 95% CI, 1.27 to 9.01) were inferior in patients infused with an A-ALC < .5 Â 10 9 lymphocytes/kg compared with patients infused with an A-ALC ! .5 Â 10 9 lymphocytes/kg, regardless of the method of collection. We did not detect significant differences in clinical outcomes or in the A-ALC collection between the modified and the standard Fenwal Amicus settings; however, despite physician discretion on primary number of collections and range of cells infused, higher A-ALC infused dose were associated with better survival after APHSCT.

Journal of Clinical Apheresis, 2013

The American Society for Apheresis (ASFA) conducted a 1 day consensus conference on Thrombotic Th... more The American Society for Apheresis (ASFA) conducted a 1 day consensus conference on Thrombotic Thrombocytopenic Purpura (TTP) during its annual meeting in Atlanta, GA, on April 10, 2012. The authors of this article, a subcommittee of ASFA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Clinical Applications Committee, developed several questions with regard to definitions, classification, pathophysiology, diagnosis, management, and future research in TTP. These questions were provided to the seven invited speakers who are the experts in the field of TTP. Two moderators conducted the proceedings of the conference which was attended by more than 100 participants. After each presentation, there was an open discussion that included moderator-selected written questions submitted by the audience. A medical writer-generated transcript of the proceedings as well as each presentation was made available to the authors. Each summary was reviewed and approved by the respective speaker before submission of this article. The subcommittee also developed seven key questions for blinded, electronic polling conducted by the moderators to generate a consensus amongst the speakers. This article includes these presentation summaries as well as results of the electronic poll.

Transplantation, 2014

Biopsy scores according to Banff criteria in the first year following transplant classified for r... more Biopsy scores according to Banff criteria in the first year following transplant classified for rejection, type of rejection and cellular component of AMR. The highest Banff score was used for each patient in the first year. This demonstrates the higher number of patients with biopsies in the antibody incompatible group (+XMKTx 39.2% and ABOiKTx 42.9%), but similar rates of cellular rejection rates in each cohort. Conventional +XMKTx ABOi Patient number 652 102 73 Number of patients biopsied % (n) 94.9% (619) 100% (102) 95.9% (70) Number of Biopsies 1651 553 340 Biopsies/pt (Mean ±StDev) 2.7 ± 1.2 5.4 ± 2.0 4.9 ± 1.8 Percentage of patients with rejection on biopsy (n) 15.7% (103)* 39.2% (40)* 41.1% (30)* * comparison made between groups using Wilcoxon rank test treating Banff score as continuous data

Transfusion, 2007

Recovery of white blood cells and platelets from leukoreduction system chambers of Trima Accel an... more Recovery of white blood cells and platelets from leukoreduction system chambers of Trima Accel and COBE Spectra plateletpheresis devices Recently, Dietz and coworkers 1 described a new source of viable peripheral blood mononuclear cells (PBMNCs) that they recovered from leukoreduction system chambers (LRSCs) of Trima Accel apheresis devices (Gambro BCT, Lakewood, CO) after routine donor plateletpheresis procedures. These white blood cells (WBCs), which are usually discarded, functioned excellently in conventional in vitro assays and therefore represent a potential and novel source for research-grade cellular products. In the following report, we describe our results comparing the yields of WBCs recovered from LRSCs in Trima Accel (software version 5.1, Gambro BCT) and COBE Spectra (software version 7.0, Gambro BCT) plateletpheresis devices. After a storage period of 2 hours at room temperature, we drained the contents of the LRSCs into 20-mL conical tubes. We counted WBCs, platelets (PLTs), and red blood cells with a blood cell counter (ADVIA 120, Bayer HealthCare Diagnostics Division, Tarrytown, NY) and quantified CD14+ monocytes by flow cytometry (FACSCalibur, BD, San Jose, CA), as previously described. 2 WBC and PLT yields were significantly different for the plateletpheresis devices (Table 1). Lymphocyte yields were greater and more consistent than monocyte yields. The minimum and maximum monocyte yields differed by 10-fold. WBC yields from Trima Accel LRSCs were 30 times greater than those from COBE Spectra LRSCs. Dietz and coworkers recovered 1.88 ¥ 10 9 PBMNCs from Trima Accel LRSCs. We recovered a mean of 66.5 percent fewer PBMNCs (0.69 ¥ 10 9 PBMNCs) from Trima Accel LRSCs. These different results may reflect actual differences in recoveries between the two plateletpheresis devices or, possibly, different instrument settings during plateletpheresis collections. For our study, we used an anticoagulant ratio of 11:1, whereas the ratio was 13:1

Neurology, 2011

Objective: To reassess the role of plasmapheresis in the treatment of neurologic disorders. Metho... more Objective: To reassess the role of plasmapheresis in the treatment of neurologic disorders. Methods: We evaluated the available evidence based on a structured literature review for relevant articles from 1995 through September 2009. In addition, due to revision of the definitions of classification of evidence since the publication of the previous American Academy of Neurology assessment in 1996, the evidence cited in that manuscript was reviewed and reclassified. Results and Recommendations: Plasmapheresis is established as effective and should be offered in severe acute inflammatory demyelinating polyneuropathy (AIDP)/Guillain-Barré syndrome (GBS) and in the short-term management of chronic inflammatory demyelinating polyneuropathy (Class I studies, Level A). Plasmapheresis is established as ineffective and should not be offered for chronic or secondary progressive multiple sclerosis (MS) (Class I studies, Level A). Plasmapheresis is probably effective and should be considered for mild AIDP/GBS, as second-line treatment of steroid-resistant exacerbations in relapsing forms of MS, and for neuropathy associated with immunoglobulin A or immunoglobulin G gammopathy, based on at least one Class I or 2 Class II studies (Level B). Plasmapheresis is probably not effective and should not be considered for neuropathy associated with immunoglobulin M gammopathy, based on one Class I study (Level B). Plasmapheresis is possibly effective and may be considered for acute fulminant demyelinating CNS disease (Level C). There is insufficient evidence to support or refute the use of plasmapheresis for myasthenia gravis, pediatric autoimmune neuropsychiatric disorders associated with streptococcus infection, and Sydenham chorea (Class III evidence, Level U). Neurology ® 2011;76: 294-300 GLOSSARY AAN ϭ American Academy of Neurology; ADEM ϭ acute disseminated encephalomyelitis; AIDP ϭ acute inflammatory demyelinating polyneuropathy; CI ϭ confidence interval; CIDP ϭ chronic inflammatory demyelinating neuropathy; CMAP ϭ compound muscle action potential; GBS ϭ Guillain-Barré syndrome; IgA ϭ immunoglobulin A; IgG ϭ immunoglobulin G; IgM ϭ immunoglobulin M; IVIg ϭ IV immunoglobulin; MG ϭ myasthenia gravis; MGUS ϭ monoclonal gammopathy of undetermined significance; MS ϭ multiple sclerosis; NDS ϭ Neuropathy Disability Scale; NMO ϭ neuromyelitis optica; OCD ϭ obsessivecompulsive disorder; PANDAS ϭ pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection; TM ϭ transverse myelitis; TTA ϭ Therapeutics and Technology Assessment.

Blood

Background: Thrombotic thrombocytopenic purpura (TTP) is a rare disorder that presents with micro... more Background: Thrombotic thrombocytopenic purpura (TTP) is a rare disorder that presents with microangiopathic hemolytic anemia and thrombocytopenia, fevers, renal insufficiency and neurologic features. We reviewed clinical, laboratory, and outcome data for TTP cases with severely deficient versus non-severely deficient ADAMTS13 activity levels. Methods: Mean and median data were from the Surveillance, Epidemiology and Risk Factors for TTP (SERF-TTP) study group for idiopathic TTP cases, the Canadian Apheresis Group (CAG), and five published series (Zheng 2004, Raife 2004, Vesely 2003 (Oklahoma TTP-HUS Registry), Matsumoto 2004 (Japan Referral Center), Bennett 2007). Results: Compared to TTP cases with near-normal ADAMTS13 activity levels (n= 282), TTP cases with severe ADAMTS13-deficiency (n=185) were more likely to have severe thrombocytopenia, normal renal function and neutralizing ADAMTS13 antibodies. Severe ADAMTS13 deficient TTP cases have better overall survival after therapeut...

Blood

Since its emergence as a novel therapy for cutaneous T-cell lymphoma in 1987, extracorporeal phot... more Since its emergence as a novel therapy for cutaneous T-cell lymphoma in 1987, extracorporeal photopheresis (ECP) has gained popularity in the fields of solid organ and stem cell transplantation (Perotti et al Transfus Apher Sci 2015). Though ECP is thought to be associated with few adverse effects, we have anecdotally noted that some patients treated with ECP develop iron deficiency anemia. Anemia has been reported in ECP literature at an incidence of anywhere from 0% to 24.5%, however, the etiology of the anemia has not been described (Quaglino et al Int J Dermatol 2013, Flowers et al Blood 2008, Jaksch et al J Heart Lung Transpl 2012, Dignan et al Bone Marrow Transpl 2014). We performed a retrospective chart review to further investigate the magnitude of this potential adverse effect. Adult patients receiving ECP for any indication at Mayo Clinic Hospital-Rochester were eligible for inclusion. Patients with pre-existing iron deficiency anemia (IDA) or physiologic and/or pharmacolo...

European Journal of Haematology

Journal of Clinical Apheresis

Journal of clinical apheresis, 2018

Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation, Jan 18, 2018

We carried out the first matched retrospective cohort study aimed at studying the safety and effi... more We carried out the first matched retrospective cohort study aimed at studying the safety and efficacy of extracorporeal photopheresis (ECP) for bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT). Medical records of 1325 consecutive adult patients who underwent HCT between 2005 and 2015 were reviewed. Seventy-four patients (median age, 51 years) with a diagnosis of BOS were included in the study. After propensity-score matching for BOS severity, 26 patients who underwent ≥3 months of ECP were matched to 26 non-ECP-treated patients, who were assigned an index date corresponding to the ECP start date for their matched pairs. The rate of decline in FEV percentage predicted (FEV) decreased after ECP initiation (and after index date in the non-ECP group), with no significant difference between the 2 groups (P = .33). On a multivariable analysis that included baseline transplant and pulmonary function test variables, matched related donor HCT ...

American journal of hematology, Jan 19, 2018

Symptomatic hyperviscosity is a well-established phenomenon in Waldenström macroglobulinemia (WM)... more Symptomatic hyperviscosity is a well-established phenomenon in Waldenström macroglobulinemia (WM). Monoclonal IgM can variably impact intrinsic serum viscosity, leading to widely disparate symptomatic thresholds for development of hyperviscosity-related symptoms. Data regarding the predictors of symptomatic hyperviscosity and outcomes related to this complication remain scarce and a recent study proposed that IgM >6000 mg/dL be considered a new criterion for initiating therapy in otherwise asymptomatic (smoldering) WM to pre-empt hyperviscosity-related injury. Herein, we attempt to identify predictors of the development of symptomatic hyperviscosity and its impact in patients with WM. Of 997 WM patients evaluated from January, 1996 through June, 2017, symptomatic hyperviscosity was observed in 130 (13%) patients. Overall survival (OS) of these 130 patients was similar to that of patients without symptomatic hyperviscosity (median: 11.5 versus 11.6 years; p=0.63). On multivariate-...

Journal of clinical apheresis, Jan 18, 2017

Apheresis procedures have a role in treatment of disparate diseases involving many different orga... more Apheresis procedures have a role in treatment of disparate diseases involving many different organ systems. Often the disease processes where apheresis plays a role in treatment are considered "orphan diseases"-relatively rare disease processes that lack specific pharmaceutical agents or established treatment protocols. Many of these disease processes can affect the eye with devastating results for the eyesight of these patients. The unique ability of apheresis to affect disease by modifying blood plasma and modulating disease-causing agents therein renders apheresis procedures valuable tools in the treatment of certain ophthalmologic diseases. This review comprehensively evaluates the role of apheresis in the treatment of ophthalmologic diseases of the eye and surrounding orbit including age-related macular degeneration, bilateral diffuse uveal melanocytic proliferation, paraneoplastic retinopathy, atopic keratoconjunctivitis, sympathetic ophthalmia, and endocrine-associa...

Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis, Jan 29, 2016

Apheresis Medicine is a medical discipline that involves a variety of procedures (based on the ta... more Apheresis Medicine is a medical discipline that involves a variety of procedures (based on the targeted component to be removed or collected), indications (therapeutic vs. donation), and personnel (operators, management, and medical oversight). Apheresis services are accredited and/or regulated by a number of agencies and organizations. Given the complexity and the heterogeneity of apheresis services, it has been particularly challenging to formulate educational goals and define curriculums that easily cover all aspects of Apheresis Medicine. This review summarizes the current state of the discipline in the United States of America, and some of the challenges, strategies, and resources that Apheresis Medicine educators have used to ensure that Apheresis Medicine educational programs meet the health care needs of the relevant population within regulatory and accrediting entity frameworks.

Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 2016

Babesiosis is a zoonotic disease transmitted by Ixodes ticks seen in the United States and parts ... more Babesiosis is a zoonotic disease transmitted by Ixodes ticks seen in the United States and parts of Europe. Because of the typically mild course of most infections, the disease is uncommonly seen in clinical practice. However, asplenic patients can develop a life-threatening infection. The first line of therapy for Babesia infections is antiparasitic medications; however, red blood cell (RBC) exchange transfusion has been described as an adjunct therapy. We describe a severe case of babesiosis in an asplenic patient and review the evidence, indications, and protocols for RBC exchange transfusion in this setting.

Mayo Clinic proceedings, Sep 3, 2016

Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common... more Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common histopathologic finding of endothelial damage resulting in microvascular thromboses and potentially serious complications. The typical clinical presentation is microangiopathic hemolytic anemia accompanied by thrombocytopenia with varying degrees of organ ischemia. The differential diagnoses are generally broad, while the workup is frequently complex and can be confusing. This statement represents the joint recommendations from a multidisciplinary team of Mayo Clinic physicians specializing in the management of TMA. It comprises a series of evidence- and consensus-based clinical pathways developed to allow a uniform approach to the spectrum of care including when to suspect TMA, what differential diagnoses to consider, which diagnostic tests to order, and how to provide initial empiric therapy, as well as some guidance on subsequent management.

The Journal of the Kentucky Medical Association, 2003

The patient benefit from reduction of an excessively elevated low density lipoprotein (LDL) chole... more The patient benefit from reduction of an excessively elevated low density lipoprotein (LDL) cholesterol is now well established, especially when there is proven coronary atherosclerosis. Dietary adherence can lower LDL cholesterol by a maximum of 10% to 15%. The addition of a cholesterol-lowering medication frequently can achieve a major LDL cholesterol reduction. However, a small group of patients with a very high LDL cholesterol respond poorly to diet and pharmaceutical treatments. These same patients have the highest incidence for very premature coronary atherosclerosis and associated cardiac events. A few medical centers, including the University of Kentucky, have established a new program to benefit these difficult high-risk patients. The technique is known as LDL apheresis, an effective process for removal of LDL cholesterol. The procedure is highly effective but very costly and third-party approval barriers are preventing access to this essential treatment for some very high-risk coronary atherosclerosis patients.

Urology, Jan 8, 2016

To evaluate the safety and efficacy of intraoperative tranexamic acid (TA), an antifibrinolytic, ... more To evaluate the safety and efficacy of intraoperative tranexamic acid (TA), an antifibrinolytic, in reducing perioperative blood transfusion (PBT) for patients undergoing open radical cystectomy (RC) for bladder cancer. We instituted a change in our institutional clinical practice starting in April 2013 whereby all patients undergoing open RC were administered intraoperative intravenous TA. Patients with a history of venous thromboembolism (VTE) or coronary stent insertion within the year prior to RC did not receive TA. Receipt of a PBT, defined as transfusion of red blood cells during RC or within the postoperative hospitalization, and VTE within 30 days of RC, were recorded and compared to a matched cohort of patients treated with RC at our center prior to the initiation of TA utilization. A total of 103 patients received TA during open RC between April 2013 and July 2015. These patients were matched 1:2 to historic controls. We found that TA infusion was associated with a signifi...

Journal of clinical apheresis, Jan 6, 2016

Anti-muscle specific kinase antibody positive (MuSK Ab) myasthenia gravis (MG) patients are known... more Anti-muscle specific kinase antibody positive (MuSK Ab) myasthenia gravis (MG) patients are known to have different clinical course compared to anti-acetylcholine receptor Ab positive MG patients. Therapeutic plasma exchange (TPE) has been reported to be effective; however, little is known of the response and of TPE procedural information. An ASFA Apheresis Registry was developed to analyze those data. The study collected detailed de-identified patient data, TPE procedures, and treatment outcome/complications. Collected data was described in aggregate. A total of 15 MuSK Ab MG patients with exacerbation of MG symptoms, 13 females/2 males, median age 44, were investigated. Thirty TPE courses (median 5 procedures/course, total 145 procedures) were evaluated. All TPE procedures were performed with citrate anticoagulation, 1 - 1.25 plasma volume exchange in 100% fluid balance, and 90% of courses used only albumin as replacement. Calcium was added to albumin or given orally as needed. TP...

Biology of Blood and Marrow Transplantation, 2016

Retrospective studies have reported that the collected and infused autograft absolute lymphocyte ... more Retrospective studies have reported that the collected and infused autograft absolute lymphocyte count (A-ALC) affects clinical outcomes after autologous peripheral hematopoietic stem cell transplantation (APHSCT). We hypothesized that manipulation of the apheresis machine to target a higher A-ALC dose would translate into prolonged progression-free survival (PFS) in patients with non-Hodgkin lymphoma (NHL) undergoing APHSCT. Between December 2007 and October 2010, we performed a double-blind, phase III, randomized study randomly assigning 122 patients with NHL to undergo collection with the Fenwal Amicus Apheresis system with our standard settings (mononuclear cells offset of 1.5 and RBC offset of 5.0) or at modified settings (mononuclear cells offset of 1.5 and RBC of 6.0). The primary endpoint was PFS. Neither PFS (hazard ratio [HR] of modified to standard, 1.13; 95% confidence interval [CI], .62 to 2.08; P ¼ .70) nor overall survival (OS) (HR modified to standard, .85; 95% CI, .39 to 1.86; P ¼ .68) were found to differ by collection method. Collection of A-ALC between both methods was similar. Both PFS (P ¼ .0025; HR, 2.77; 95% CI, 1.39 to 5.52) and OS (P ¼ .004; HR, 3.38; 95% CI, 1.27 to 9.01) were inferior in patients infused with an A-ALC < .5 Â 10 9 lymphocytes/kg compared with patients infused with an A-ALC ! .5 Â 10 9 lymphocytes/kg, regardless of the method of collection. We did not detect significant differences in clinical outcomes or in the A-ALC collection between the modified and the standard Fenwal Amicus settings; however, despite physician discretion on primary number of collections and range of cells infused, higher A-ALC infused dose were associated with better survival after APHSCT.

Journal of Clinical Apheresis, 2013

The American Society for Apheresis (ASFA) conducted a 1 day consensus conference on Thrombotic Th... more The American Society for Apheresis (ASFA) conducted a 1 day consensus conference on Thrombotic Thrombocytopenic Purpura (TTP) during its annual meeting in Atlanta, GA, on April 10, 2012. The authors of this article, a subcommittee of ASFA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Clinical Applications Committee, developed several questions with regard to definitions, classification, pathophysiology, diagnosis, management, and future research in TTP. These questions were provided to the seven invited speakers who are the experts in the field of TTP. Two moderators conducted the proceedings of the conference which was attended by more than 100 participants. After each presentation, there was an open discussion that included moderator-selected written questions submitted by the audience. A medical writer-generated transcript of the proceedings as well as each presentation was made available to the authors. Each summary was reviewed and approved by the respective speaker before submission of this article. The subcommittee also developed seven key questions for blinded, electronic polling conducted by the moderators to generate a consensus amongst the speakers. This article includes these presentation summaries as well as results of the electronic poll.

Transplantation, 2014

Biopsy scores according to Banff criteria in the first year following transplant classified for r... more Biopsy scores according to Banff criteria in the first year following transplant classified for rejection, type of rejection and cellular component of AMR. The highest Banff score was used for each patient in the first year. This demonstrates the higher number of patients with biopsies in the antibody incompatible group (+XMKTx 39.2% and ABOiKTx 42.9%), but similar rates of cellular rejection rates in each cohort. Conventional +XMKTx ABOi Patient number 652 102 73 Number of patients biopsied % (n) 94.9% (619) 100% (102) 95.9% (70) Number of Biopsies 1651 553 340 Biopsies/pt (Mean ±StDev) 2.7 ± 1.2 5.4 ± 2.0 4.9 ± 1.8 Percentage of patients with rejection on biopsy (n) 15.7% (103)* 39.2% (40)* 41.1% (30)* * comparison made between groups using Wilcoxon rank test treating Banff score as continuous data

Transfusion, 2007

Recovery of white blood cells and platelets from leukoreduction system chambers of Trima Accel an... more Recovery of white blood cells and platelets from leukoreduction system chambers of Trima Accel and COBE Spectra plateletpheresis devices Recently, Dietz and coworkers 1 described a new source of viable peripheral blood mononuclear cells (PBMNCs) that they recovered from leukoreduction system chambers (LRSCs) of Trima Accel apheresis devices (Gambro BCT, Lakewood, CO) after routine donor plateletpheresis procedures. These white blood cells (WBCs), which are usually discarded, functioned excellently in conventional in vitro assays and therefore represent a potential and novel source for research-grade cellular products. In the following report, we describe our results comparing the yields of WBCs recovered from LRSCs in Trima Accel (software version 5.1, Gambro BCT) and COBE Spectra (software version 7.0, Gambro BCT) plateletpheresis devices. After a storage period of 2 hours at room temperature, we drained the contents of the LRSCs into 20-mL conical tubes. We counted WBCs, platelets (PLTs), and red blood cells with a blood cell counter (ADVIA 120, Bayer HealthCare Diagnostics Division, Tarrytown, NY) and quantified CD14+ monocytes by flow cytometry (FACSCalibur, BD, San Jose, CA), as previously described. 2 WBC and PLT yields were significantly different for the plateletpheresis devices (Table 1). Lymphocyte yields were greater and more consistent than monocyte yields. The minimum and maximum monocyte yields differed by 10-fold. WBC yields from Trima Accel LRSCs were 30 times greater than those from COBE Spectra LRSCs. Dietz and coworkers recovered 1.88 ¥ 10 9 PBMNCs from Trima Accel LRSCs. We recovered a mean of 66.5 percent fewer PBMNCs (0.69 ¥ 10 9 PBMNCs) from Trima Accel LRSCs. These different results may reflect actual differences in recoveries between the two plateletpheresis devices or, possibly, different instrument settings during plateletpheresis collections. For our study, we used an anticoagulant ratio of 11:1, whereas the ratio was 13:1

Neurology, 2011

Objective: To reassess the role of plasmapheresis in the treatment of neurologic disorders. Metho... more Objective: To reassess the role of plasmapheresis in the treatment of neurologic disorders. Methods: We evaluated the available evidence based on a structured literature review for relevant articles from 1995 through September 2009. In addition, due to revision of the definitions of classification of evidence since the publication of the previous American Academy of Neurology assessment in 1996, the evidence cited in that manuscript was reviewed and reclassified. Results and Recommendations: Plasmapheresis is established as effective and should be offered in severe acute inflammatory demyelinating polyneuropathy (AIDP)/Guillain-Barré syndrome (GBS) and in the short-term management of chronic inflammatory demyelinating polyneuropathy (Class I studies, Level A). Plasmapheresis is established as ineffective and should not be offered for chronic or secondary progressive multiple sclerosis (MS) (Class I studies, Level A). Plasmapheresis is probably effective and should be considered for mild AIDP/GBS, as second-line treatment of steroid-resistant exacerbations in relapsing forms of MS, and for neuropathy associated with immunoglobulin A or immunoglobulin G gammopathy, based on at least one Class I or 2 Class II studies (Level B). Plasmapheresis is probably not effective and should not be considered for neuropathy associated with immunoglobulin M gammopathy, based on one Class I study (Level B). Plasmapheresis is possibly effective and may be considered for acute fulminant demyelinating CNS disease (Level C). There is insufficient evidence to support or refute the use of plasmapheresis for myasthenia gravis, pediatric autoimmune neuropsychiatric disorders associated with streptococcus infection, and Sydenham chorea (Class III evidence, Level U). Neurology ® 2011;76: 294-300 GLOSSARY AAN ϭ American Academy of Neurology; ADEM ϭ acute disseminated encephalomyelitis; AIDP ϭ acute inflammatory demyelinating polyneuropathy; CI ϭ confidence interval; CIDP ϭ chronic inflammatory demyelinating neuropathy; CMAP ϭ compound muscle action potential; GBS ϭ Guillain-Barré syndrome; IgA ϭ immunoglobulin A; IgG ϭ immunoglobulin G; IgM ϭ immunoglobulin M; IVIg ϭ IV immunoglobulin; MG ϭ myasthenia gravis; MGUS ϭ monoclonal gammopathy of undetermined significance; MS ϭ multiple sclerosis; NDS ϭ Neuropathy Disability Scale; NMO ϭ neuromyelitis optica; OCD ϭ obsessivecompulsive disorder; PANDAS ϭ pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection; TM ϭ transverse myelitis; TTA ϭ Therapeutics and Technology Assessment.